© 2012 by Geisinger Health System – All Rights Reserved Not for reuse or distribution without permission Innovations That Have Driven Geisinger’s Performance

© 2012 by Geisinger Health System – All Rights Reserved

Not for reuse or distribution without permission

Innovations That Have Driven

Geisinger’s Performance

Earl Steinberg, MD, MPP EVP, Innovation & Dissemination

Geisinger Health System

GEISINGER–An Integrated Health Services Organization

Provider Facilities$1,671M

PhysicianPractice Group

$757M

Managed Care Companies

$1,541M

Geisinger Medical Center & Geisinger Shamokin Area Community Hospital Geisinger Wyoming Valley Medical Center Geisinger Community Medical Center Geisinger Bloomsburg Hospital 2 Nursing Homes 3 Surgery Centers 77K admissions/OBS & SORUs 1,619 beds

Multispecialty group ~1,029 employed physicians ~600 advanced practitioners 73 primary & specialty clinic sites ~2.1M clinic outpatient visits ~464 resident & fellow FTEs

~322K members (including ~68K Medicare Advantage members)

Diversified products

~34K contracted providers/facilities

43 PA counties

Strictly Confidential and Proprietary

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Geisinger Health System coverage area

Revised 12-12-12. Geisinger PR & Marketing Department

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Overview of Strategic PlanQuality and Innovation

– Patient centered focus• Patient activation (empowerment)• Culture of quality, safety and health

– Value re-engineering• Transformational changes – embedding innovations

Market Leadership– Collaboration/partnerships

(local, regional, national)– The GHS Brand

• Scaling and generalizing

The Geisinger Family– Personal and professional well being

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Key Process Redesign StrategiesFocus on quality and efficiency of care.

Agree on standardized “production functions”.

Eliminate steps that are unnecessary.

Automate any work that can be automated.

Delegate work to appropriately trained non-physician staff when possible. (All personnel to “operate at the top of their license”.)

Support agreed upon workflows with various types of EMR reminders, decision support tools and work flow facilitators to increase the reliability of the care provided.

Activate and engage the patient and their family.


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Major Geisinger Re-Engineering Initiatives

• Enterprise Data Warehouse• Make the EMR a Member of the Team• Primary Care Redesign• ProvenCare® (Acute and Chronic)• ProvenHealth® Navigator (Advanced Medical Home)• Transitions of Care• GAPP (Geisinger Accelerated Performance Program)


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Alerts Prompts/Reminders Order Sets Automated care plans Patient messages Information Rx …

Effectors

…

EBM GuidelinesPatient Preferences

Formulary/Economics

Other Inputs

EHR

Clinical, Schedule

…

Real-time Clinical Status

Decision Support

CDIS

Normalization, Transformation, Analytic Application

FinanceClaims Ops

…

Clinical Decision Intelligence System (CDIS)

…Po

pula

tion

Tre

nds

Empi

rica

l Nor

ms


Electronic Health Record (EHR)

• Decision to implement Epic®: 1995• ~$135M invested in hardware, software, manpower,

training prior to 2012 hospital acquisitions • EPIC Team: 200 employed FTEs + 70 contracted FTEs• Operating costs: >$25M per year• EHR fully-integrated across all ambulatory and inpatient

sites of care (In process for recently acquired hospitals)• > 3.8 million distinct patient records • ~ 4,000 non-Geisinger users (referring physicians)

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Regular Care

100% Care Processes and Protocols (Digital)

AutomationPatient

Activation

Populations

Workflow Modification

Patients and Conditions

Population Identification

Bundle Development

Delegation and

Algorithms

Low Efficiency and Reliability High

Reengineering Clinical Care


Closing Care Gaps: Content, People and Health Information Technology (HIT) PeopleContent HIT

Heart Failure

HTN and LipidsObesity

CKD

*End of Life

Vascular DiseaseOsteoporosis

Asthma/COPD

*Medication Safety

Automating orders

Real-time opportunity reports

Clinical WorkgroupsClinical Data Capture

DiabetesPrevention

CAD Problem List Manager

Office-Based Decision Support

Automating outreach

Diagnosis Naming Conventions

Medical Informatics

Innovation

EPIC Design Team

Data Visualization

Patient Reported Data Capture

*Atrial Fibrillation

Analytics and IT

Care Gaps Manager

Patient Communication

Care Gaps Team

Outpatient Reengineering and Innovation Oversight

Scheduling Services


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ProvenCare® for Acute Episodic Care

• Identified best practices• Developed operational definitions when needed• Obtained MD buy-in • Developed tools to facilitate compliance with best

practices and integrated them into work flow• Provided financial incentives to comply• Monitor performance


• Carotid Eval• Vascular Consult• Inf.MI/RV• Clopidogrel• Warfarin• Beta Blockade• Smoking Cessation

• Beta Blockade

• Clopidogrel

• Warfarin

• Antibiotics• Glycemic Control• IABP use• Atherosclerotic

Aortas• Cardioplegia• Arterial Conduits

• Antibiotics• Glycemic Control• Beta Blockade• ASA Therapy• Afib prevention• Lipid

management• Ant.MI/WMA• Smoking

Cessation

• Beta Blockade• ASA Therapy• Lipid

management• Cardiac Rehab• Smoking

Cessation

Clinic Pre-op OR Post-opReturn Clinic

1211

ProvenCare® CABG: Process flow


ProvenCare® & the Electronic Medical Record (EMR)

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Reporting Period: FY2011 Q4 Apr-JunUpdate Date: July 5, 2011

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Clinical Outcomes:O / E ratios for STS risk-adjusted outcomes

BeforeProvenCare®

N = 132

AfterProvenCare®

N = 554

% Improvement

(Deterioration)

Mortality 0.85 0.46 46 %

Prolonged ventilation 1.22 0.97 20 %

Deep sternal wound infection

1.15 0.41 64 %

Re-operation 1.14 1.07 6 %

Patients with any complication (STS)

1.00 1.08 (7 %)

Permanent stroke 1.04 1.18 (13 %)

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Base Line (FY2006)

Look Back (FY2010)

Variance

Cases 116 131 15

LOS (days) 7.60 6.28 (1.32)

CM Per Case ($) 17,810 21,949 4,139

Net Revenue per Case ($) 35,482 43,429 7,947

Financial Results: CAB

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Current Status: NICU Admission Rates

NICU Admission Rates and LOS for Pre and Post-ProvenCare Implementation

• All patients are classified as "GHS patients." This means the mothers of the infants were seen for at least 13 weeks prior to delivery by a GHS provider and delivered in a GHS hospital.

• All patients were admitted to the NICU within 24 hours of birth.

• Pre-ProvenCare represents the period from January 2007-March 2009 (27 months)

• Post-ProvenCare represents the period from April 2009-Dec 2010 (21 months)

Definitions and inclusion criteria

Chi square p-value for NICU admission: <0.01

Patient GroupGHS NICU

admitsTotal GHS deliveries

% admitted to NICU Average LOS

Pre-ProvenCare 427 4435 9.6 18.7Post-ProvenCare 321 4176 7.7 16.8


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ProvenCare® - Chronic Disease

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Improved Care for 25,071 Diabetics3/06 3/07 8/10 8/11

Diabetes Bundle Percentage* 2.4% 7.2% 13.0% 12.5%

% Influenza Vaccination 57% 73% 75% 76%

% Pneumococcal Vaccination 59% 83% 83% 82%

% Microalbumin Result 58% 87% 78% 78%

% HgbA1c at Goal 33% 37% 52% 50%

% LDL at Goal 50% 52% 54% 55%

% BP < 130/80 39% 44% 55% 57%

% Documented Non-Smokers 74% 84% 85% 85%

* Represents % of pts in whom all indicated services were provided


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Improved Care for 15,532 CAD Patients

9/06 3/07 8/10 8/11

CAD Bundle Percentage 8% 11% 22% 23%

% LDL <100 or <70 if High Risk

38% 37% 50% 52%

% ACE/ARB in LVSD,DM, HTN 65% 66% 76% 77%

% BMI measured 79% 86% 99% 99%

% BP < 140/90 74% 74% 79% 81%

% Antiplatelet Therapy 89% 91% 92% 93%

% Beta Blocker use S/P MI 97% 97% 97% 97%

% Documented Non-Smokers 86% 86% 87% 87%

% Pneumococcal Vaccination 80% 80% 86% 86%

% Influenza Vaccination 60% 74% 78% 78%


Improved Preventive Care for 220,946 Patients11/07 8/11

Adult Preventive Bundle 9.2% 31%

Breast Cancer Screening (q 2 40-49, q 1 50-74) 46% 61%

Cervical Cancer Screening (q 3 yr Age 21-64) 64% 71%

Colon Cancer Screening (Age 50-84) 44% 66%

Prostate Cancer Discussion (Age 50-74) 72% 77%

Lipid Screening (Every 5 yr M > 35, F > 45) 75% 87%

Diabetes Screening (Every 3 yr > 45) 85% 90%

Obesity Screening (BMI in Epic) 77% 97%

Documented Non-Smokers 75% 78%

Tetanus Diphtheria Immunization (every 10 yr) 35% 72%

Pneumococcal Immunization (Once Age >65) 84% 86%

Influenza Immunization (Yearly Age >50) 47% 59%

Chlamydia Screening (Yearly Age 18-25) 22% 37%

Osteoporosis Screening (every 3 yr Age > 65) 52% 73%

Alcohol Intake Assessment 84% 92%


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ProvenHealth Navigator®

(Advanced Medical Home)

• Partnership between primary care physicians and Geisinger Health Plan (GHP)

• GHP nurses embedded in primary care practices• Easy, reliable phone access for patients• Follow-up calls after hospitalizations and ER visits • Telephonic and digital monitoring• Group visits/educational services• Personalized tools (e.g., chronic disease report

cards)


Medicare Risk Adjusted Acute Admissions Per 1000

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2006 2007 2008 2009 2010 20110

50

100

150

200

250

300

350309 300 303 292 286 276

257240 232 240

226

295

PHN Non-PHN 44 Current PHN Sites


Medicare Risk Adjusted Readmissions/1000

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2006 2007 2008 2009 2010 20110

5

10

15

20

25

30

35

40

45

50 47 46 4744

42 4141

3034 34

31

44


Medicare Risk Adjusted ER Visits/1000

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2006 2007 2008 2009 2010 20110

50

100

150

200

250

300

350

264250

264284 295

329

293

262 257 260 262267



ProvenHealth Navigator® Reduces Cost Trend

-12%

-10%

-8%

-6%

-4%

-2%

0%Q

1 2

00

5

Q3

20

05

Q1

20

06

Q3

20

06

Q1

20

07

Q3

20

07

Q1

20

08

Q3

20

08

Q1

20

09

Q3

20

09

95% Confidence Interval

Median Estimate


Cumulative percent difference in spending (Pre-Rx Allowed PMPM $) attributable to PHN in the first 21 PHN clinics for calendar years 2005-2009. Dotted lines represent 95% confidence interval. P = < 0.003Source: Reducing Long-Term Cost by Transforming Primary Care: Evidence From Geisinger's Medical Home Model (Am J Manag Care. 2012;18(3):149-155)

• Medical expense trend reduced by

7.1%, p<.01

• ROI for all years 2007-2010, with Rx

coverage = 1.7



Median Estimate

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Key Characteristics of Geisinger Health System

Strong physician leadership

paired with admin. partner

Organizational culture that

prioritizes quality, efficiency

and innovation

Work force that embraces

the culture

A clinical enterprise and a

health plan

Clear, shared aims

Incentives aligned with aims

Team and system of care

orientation

Infrastructure (IT, IM, EMR,

Data Analytics)

Skunk works and

transformation units

Focus on work flow and

reliability

Performance measurement

and feedback


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Payment Changes Creating New Market Needs

• Changes in the way health care is paid for is prompting many health care providers to begin to change how they are organized and deliver care.

• Most providers lack the capabilities that will be required to be successful under risk- and/or performance-based payment.

• Health care providers thus will need help to transition from a volume- to a value-oriented payment system


Consulting

Population Health Data Analytics

Care Management

Third Party Administration

EHR Applications, Including Licensing Intellectual Property 30

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Relationship between GHS and xG Health Solutions

GHS “Core Operations”

Engine of

IP Development

Clinical

Enterprise

Geisinger

Insurance

Organization

Researc

h

Geisinger

Support

Services

Newco IP

“Productization”

Health Care Delivery Systems

Insurers

Product Manufacturers

Execute Core Business/Innovate Generalize/Disseminate/$ Return

EMR Vendors

IP

xG“Product Development & Service Delivery”

Innovation & Transformation

Quality & Safety

Products/Services

ACO Support Services

Consulting

Software Apps

ASP Software Solutions

IP Licensing

Medicare FFS / Advantage

Assets in Newco

Financial Capital

Human Capital

Partner relationships

Administrative resources

Technology Resources


xG Products and Services

Services to Support Value-Driven Care Population Health Data Analytics Care Management

Consulting Services

Licensing Geisinger IP to product manufacturers and health care delivery systems

Software apps based on Geisinger IP (possibly)


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Target market for xG service offerings


Commercial

Customers

Medicare

Customers

Health System Employees and Dependents

Self-insured providers seeking to reduce their own health care costs; view as “safest” place to start, no need to share savings

• 250+ systems with 10,000+ EE opportunity

Health System All Payer Shared Savings Model

Health systems want to employ more uniform infrastructure for shared savings plans across all commercial payers• Commercial and Government business

• 194.5mm Americans have private health insurance

• Concentration amongst the largest 25 providers

Large Local/Regional Employers

Large regional employers looking to reduce medical costs through direct partnership with health systems; health systems looking to “lock in” lives

• 158 MSAs with population 300,000+

• 314 MSAs with population 120,000+

Medicare Advantage

Provider (or insurer) offering MA plan benefits from capabilities that improve their performance

• 1,974 plans

• >13mm MA lives

Medicare ACOMany providers participating in CMS ACO programs looking to buy vs. build capabilities needed to be successful

• 49mm Medicare lives

• 154 shared savings programs in place

• 400 LOIs for 1/13 MSSPs

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Geisinger Consulting Group Services

• Organizational strategy, leadership and transformation• MD compensation and alignment• ACO readiness• Primary care redesign• EMR optimization• ProvenCare®

• Patient-centered medical home model• Embedded case manager certification• Care transitions• Bundled payment• Inpatient efficiency


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Information Management/Data Analysis/Reporting Svcs.

Data management

• Substantial experience/expertise in obtaining and integrating data

• Exceptional experience and expertise in QA-ing data


Data Analytics

• Algorithms/Software programs to perform actuarial analyses

• Experience analyzing EMR data and Algorithms/Software programs to perform clinical analyses of claims data and EMR data

• Expertise in interpreting the results for those analyses – much of this can be automated

Care Management

• ProvenCare®, ProvenHealth Navigator®, numerous templates used by case managers, primary care re-design methods, etc.

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Actuarial informatics process


• Produce Medical Expense Trend Report (METR)• Utilization Per 1,000; Unit Costs, Cost Projections • ID of cost and utilization drivers; drill down capability

Assess Customer’s Current and Historical Care Costs

• Compare experience to Geisinger and national benchmarks and identify drivers of admissions, readmissions, Rx costs etc.

• Are costs driven by excess Utilization, high Unit Costs or both? What utilization represent biggest opportunities?

• Prospects for reduction of unit costs and out of network utilization?

Identify Opportunities to Reduce Care Costs

Gain “Action Item” Consensus

Estimate Anticipated Cost Savings

Monitor Actual Cost Savings

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• Predictive modeling to identify patients with highest cost risk

• Clinical segmentation to identify patients with highest clinical risk

• Identification of specific, actionable “gaps in care”

• Assessment of quality of care being delivered to entire population

• Provider profiling

• Quality of care

• Cost of care

• Drivers of cost of care

• Reporting

• Executive dashboard

• Clinical overview for CMO

• MD-specific profiles

Clinical data analytics process


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Differentiated Medical Management


Acute Care Management

Chronic Care Management

• Primary care re-design • Proven PCMH Model • Specially selected/trained

embedded case managers • Standardized

processes/protocols, including ProvenCare® chronic, case management workflows

• Data analytically driven EBM

• Medical Neighborhood (Continuum of Care)

• Transitions of Care Model

• ProvenCare® Acute• Strategies to increase

efficiency • Transitions of Care Model

Patient Identification and

Stratification

• Screenings• Data-analytically driven ID

of needs • Automated outreach

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Licensing Geisinger IP• Types of IP - Software prototypes (e.g. for managing workflow in anatomic and cyto-

pathology labs; for managing patients with rheumatoid arthritis, low back

pain or headache)

- Clinical content (e.g. care protocols, order sets, discharge instructions)

- Clinical decision support tools (e.g. triggers for best practice alerts for

MDs, nurses and patients)

- Work flow facilitators (e.g. flow sheets, templates, algorithms)

- Technical specifications for data analyses and reports

• Potential Licensees

- Health care delivery systems

- Insurers

- EMR vendors

- Other product/software manufacturers (e.g. McKesson, Trizetto, IBM)

- Consulting firms


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Web-based Apps Based on Geisinger IP (“Geisinger in the Cloud”)

• Exploring feasibility of having apps exchange data with EMRs

• Examples of Potential Apps: - Management of patients with particular problems (e.g. rheumatoid

arthritis)

- ProvenCare modules (e.g. CABG, diabetes, perinatal care), including reports on compliance

- Patient referrals to highest quality/lowest cost providers

- Patient scheduling

- Hospital discharge (transition of care)

- Work flow support for case manager embedded in PCMH

- Clinical decision support tools

- Templates for collection of standardized data for research collabs.


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Questions We Hope to Answer

• Reproducible?• Scalable?• Similar impacts?


Documents

© 2012 by Geisinger Health System – All Rights Reserved Not for reuse or distribution without permission Innovations That Have Driven Geisinger’s Performance